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APPLICATION FOR PERMIT t� S <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES i <br /> ENVIRONMENTAL HEALTH DIVISION NSW <br /> 1601 E. HAZELTON AVE. ,PHONE (209)468-3420 �a <br /> P O BOX 2009, ST, OCKTON� CA 95201 V-9- <br /> ,^ -_ <br /> %P RES 1 YEAR FROM DA E �"" �""n <br /> (Complete in Triplicate) ke <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San i <br /> Joaquin County Public Health Services. ' l <br /> City Lot Size/Acreage <br /> Job Addres� <br /> * .X/ , (C�� Phone <br /> Owner's Name Address — �t <br /> ContractorL Address c <br /> License No. Phone ^� <br /> TYPE OF LL/PUMP: NEW WELL ❑ WELL REPLACE�ENT DESTRUCTION Cl put of Service well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ Y <br /> OTHER C� Monitoring well <br /> SEWER LINES - DISPOSAL FLD. PROP, LINE <br /> G DISTANCE TO NEAREST::SEPTIC TANK,- --" AGRICULURE WELL OTHER'WELL PITS/SUMPS <br /> .FOUN0ATI0N ___�— T_ <br /> kINTENDED USE TYPE OF WELL. .--PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> I [ 1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Type of Casing ' Specifications <br /> [-I Domestic I Private ❑ Gravel Pack 0 Tracy yp ` Type of Grout <br /> 11 I'i Public la Other n Delta Depth of Grout Seal' <br /> I I Public <br /> :-.Approx.-Depth- 'f 1'Eastern Surface-Seal-installed by - <br /> H P State Work Done _ <br /> Repair Work Done 0 'Type of Pump Sealing Material & Depth, <br /> Well Destruction ❑ Well Diameter �� -- Filler Material & Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRlADDITION I I DESTRUCFIOAi 1 INailablelwiy 20Wdepih pe <br /> stem Installation will serve: #Residence 'Commercial_ Other� -- i <br /> Number of living units: Numbef of bedrooms Water tableChiractef of soil to a depth of 3 feet: Na. CompaSEPTIC TANK. 0 Type/Mfg Capacity — Method of <br /> PKG.'TAEATMENT PLT. Cl ` Property Line <br /> Distance to nearest: Well Foundation p y <br /> M r <br /> LEACHING LINE DNo. & Length of lines <br /> Total length/size <br /> i FILTER'BED f_7 Distance to nearest: Well <br /> Foundation Property Line <br /> t SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS <br /> and that the work will be done in accordance with Sart Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this application <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed i#gent's signature certifies the following: l_cQrtify,that in the_perforf California." <br /> rn the work for which this f pernit is issued, k shall not <br /> employ any person in such manner as to become subject to workman's compensation laws ss ed,I rnia." Contractors hiring c sub contracting signature <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must I for all require 'nsPections. Complete drawing on rev ` 3 3or� D <br /> Title: <br /> Signed X 1 Date: - <br /> r _ DEPARTMENT.-USE DNLY _ <br /> Date 3 O __ Area <br /> Application Accepts by <br /> LL -""°"� Firial Inspection by� � `Date <br /> Pittor Grout Inspection by Osie — <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P O Box 2009, Stockton, CA. 95201 <br /> 1 S CK <br /> r FEE MOUNT DUE AMOUNT REMITTED G SHRECEIVED BY ;DATE PERMIT'NO. <br /> I INFO 12 <br /> 'r /Q <br /> f . EH 13-241REV-1/n51 � v � �� D <br /> EH 94.26 0� <br />